- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.41 / $2,056.41 / $8,500.00
| Facility | | $2,056.41 | $2,056.41 | $8,500.00 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $1,968.54 / $2,056.41 / $2,056.41
| Professional | | $1,968.54 | $2,056.41 | $2,056.41 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $4,278.38 / $4,667.93 / $5,595.83
| Professional | | $4,278.38 | $4,667.93 | $5,595.83 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,648.91 / $4,738.68 / $6,119.33
| Professional | | $2,648.91 | $4,738.68 | $6,119.33 |
- Facility/Professional
- Facility
- Modifier
- Low / Median / High Price
- $2,056.41 / $2,870.05 / $6,169.23
| Facility | | $2,056.41 | $2,870.05 | $6,169.23 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.56 / $3,897.78 / $5,242.85
| Professional | | $2,272.56 | $3,897.78 | $5,242.85 |
- Facility/Professional
- Professional
- Modifier
- Low / Median / High Price
- $2,272.56 / $4,151.54 / $5,242.85
| Professional | | $2,272.56 | $4,151.54 | $5,242.85 |